Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 109 num. 4 lang. <![CDATA[SciELO Logo]]> <![CDATA[<b>Anti-vaxx - wilful ignorance or misunderstanding?</b>]]> <![CDATA[<b>Eligibility for co-trimoxazole prophylaxis among adult HIV-infected patients in South Africa</b>]]> <![CDATA[<b>Low-pressure fabric hyperbaric chambers</b>]]> <![CDATA[<b>Hardie de Beer, 8 August 1943 - 9 December 2017</b>]]> <![CDATA[<b>Eric Cohen, 3 February 1943 - 31 December 2018</b>]]> <![CDATA[<b>Waking Up Safer? An Anesthesiologist's Record</b>]]> <![CDATA[<b>Understanding the genetic basis of human health and disease: Role of molecular genetics in diagnosis and prognostication</b>]]> <![CDATA[<b>New genetic testing technologies: Advantages and limitations</b>]]> Genetic testing has been available for many years. Recently, the potential for increased and more precise diagnostic testing has expanded, with the introduction of next-generation sequencing technologies. Testing is complex and requires the experience of medical geneticists and genetic counsellors to assist in selecting the most appropriate test for a patient, as well as in interpreting the large data sets that arise from such testing. The most appropriate test for a patient may require analysis of only one base of DNA, or one gene, one panel, a whole exome or a whole genome. The interpretation of positive findings is challenging and requires careful distinction between benign and pathogenic variants. Variants of uncertain significance occur; unexpected findings are not infrequent and require careful interpretation and management. The paucity of data on normal variation poses specific challenges on the African continent. <![CDATA[<b>Investigating developmental delay in South Africa: A pragmatic approach</b>]]> Global developmental delay and intellectual disability are common disorders in every population, with a prevalence of 1 - 5%. Although a specific cause is not always immediately identifiable, for many affected people the aetiology is genetic or the result of secondary insult to the developing brain. Investigating children with intellectual developmental disorders (IDD) may be a significant challenge, especially in resource-limited settings. Comprehensive clinical evaluation is the first step and frequently determines the direction of further investigations. Hearing and vision screening and thyroid function tests should be performed in most patients. Children with neurological findings should undergo brain imaging, and careful consideration should be given to potential metabolic disorders in all children with IDD, a number of whom are amenable to treatment. Most children in whom a specific direction is not suggested after history-taking and examination, should be tested for chromosomal abnormalities, ideally with chromosomal microarray, which has a diagnostic detection rate of 8 - 20% in IDD. Additional tests may be indicated in particular settings, including broad-based testing for single-gene disorders, such as next-generation sequencing gene panels or exome analysis. All genetic testing has the potential of finding variants of uncertain significance, particularly when there are limited population data, such as in Africa. Making a specific diagnosis in IDD is of benefit to patients, their families and society. Therefore, a rational approach to investigating this group of patients is essential to maximise the health benefit in a cost-effective way. <![CDATA[<b>Cancer genetics: An approach to suspected hereditary breast or colorectal cancer</b>]]> Two of the most common cancers are breast cancer and colorectal cancer. Up to 10% of cases of each are associated with a high risk of recurrence in an affected individual, or of occurrence in biological relatives. This results from the presence of an underlying mutation (or 'pathogenic variant') in a high-penetrance gene. Such cases are typically associated with an autosomal dominant pattern of inheritance, although this may not be obvious in the family history. Genetic testing can identify many (but not all) of these cases, and should be offered to those whose family history or clinical features suggest a high risk. Although testing for certain risk genes (e.g. BRCA1 or BRCA2) has been available for years, the advent of next-generation sequencing gene panels' now allows for simultaneous testing of many more genes at lower cost. This allows for more frequent detection of pathogenic variants in underlying genes than in the past, but also makes interpretation more complex. An index of suspicion for genetic cancers and appropriate referral to a genetics health professional are increasingly important. <![CDATA[<b>The utility of hand-held mobile spirometer technology in a resource-constrained setting</b>]]> BACKGROUND: Mobile phone-linked spirometry technology has been designed specifically for evaluating lung function at primary care level. The Air-Smart Spirometer is the first mobile spirometer accepted in Europe for the screening of patients with chronic respiratory diseases OBJECTIVES: To prospectively assess the accuracy of the device in measuring forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC) in a South African population, and to investigate the ability of the device to detect obstructive ventilatory impairment METHODS: A total of 200 participants were randomly assigned to perform spirometry with either the mobile spirometer connected to a smartphone or the desktop spirometer first, followed by the other. The FEV1/FVC ratio as well as the absolute FEV1 and FVC measurements were compared, using each participant as their own control. A Pearson correlation and Bland-Altman analysis were performed to measure the agreement between the two devices. We defined obstructive ventilatory impairment as FEV1/FVC <0.7 measured by desktop spirometry in order to calculate the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the Air-Smart Spirometer RESULTS: There was a strong correlation between the absolute FEV1 and FVC values and FEV1/FVC ratio measured with the mobile AirSmart Spirometer and more conventional pulmonary function testing, with r=0.951, r=0.955 and r=0.898, respectively. The Air-Smart Spirometer had a sensitivity of 97.6%, specificity of 74.4%, PPV of 73.0% and NPV of 97.8% for obstructive ventilatory impairment CONCLUSIONS: The mobile Air-Smart Spirometer compared well with conventional spirometry, making it an attractive and potentially affordable tool for screening purposes in a primary care setting. Moreover, it had a high sensitivity and NPV for obstructive ventilatory impairment <![CDATA[<b>Spotted fever rickettsiosis in South Africa: Evaluation of laboratory diagnostic capacity and inter-laboratory comparison of serological testing</b>]]> BACKGROUND: Spotted fever rickettsiosis, also known as tick bite fever (TBF), is a common infectious disease in South Africa (SA). Although the diagnosis of TBF is often based on clinical grounds only, laboratory testing is important to confirm the diagnosis and can contribute to case management in the light of a myriad of differential diagnoses, and in complicated cases OBJECTIVES: To report on the availability and scope of laboratory tests for investigating suspected cases of TBF in SA, and the outcome of an inter-laboratory comparison (ILC) conducted for serological tests METHODS: A self-administered questionnaire was circulated to major pathology laboratories in SA to determine what TBF tests they offered for TBF investigation. In addition, a clinical panel was provided to willing laboratories in order to perform an ILC of the serological tests RESULTS: Serological tests for TBF were available from five laboratories serving both the private and state medical sectors in SA. There was no standardised testing platform or result interpretation across the different laboratories. Polymerase chain reaction (PCR) tests were less frequently available, and not available to state-operated facilities. The outcome of the ILC indicated varied performance and interpretation of serological results for TBF CONCLUSIONS: Laboratory investigation for TBF is routinely and widely available in SA. Both serological and PCR-based methods were varied, and the lack of standardisation and interpretation of tests needs to be addressed to improve the overall quality of TBF diagnosis in SA. The utility of ILC to identify problem areas in serological testing for TBF is highlighted, and laboratories in SA are encouraged to use it to improve the quality of testing <![CDATA[<b>HIV self-screening distribution preferences and experiences among men who have sex with men in Mpumalanga Province: Informing policy for South Africa</b>]]> Current research suggests that HIV self-screening (HIVSS) is a feasible and acceptable approach to increase HIV testing among men who have sex with men (MSM). However, few data are available to shape policy around dissemination and implementation. Gaps in knowledge include preferences for distribution of HIVSS kits, potential social harms and benefits of their use, and how much test users would be willing to pay for the kits. The aim was to inform policy recommendations to optimise distribution of HIVSS kits to MSM in South Africa (SA), where there is a high HIV incidence and unmet testing needs. MSM in the high-HIV-prevalence Gert Sibande and Ehlanzeni districts of Mpumalanga Province, SA, were enrolled between October 2015 and May 2017. Participants were provided with their choice of blood or oral fluid HIVSS test kits, receiving 5 kits at enrolment and 4 additional kits at the 3-month follow-up visit. Questionnaires were administered at enrolment, 3 months and 6 months. We analysed participants' reported social benefits and harms, and their preferences for kit distribution and pricing. Among 127 MSM screened and enrolled, 114 responded to follow-up questionnaires regarding distribution preferences, 49.3% preferred to acquire HIVSS kits at a community-based organisation (CBO) and 42.7% at a clinic, with 8% preferring a pharmacy. Participants with higher education preferred CBO sites for distribution; in other respects preferences were similar by demographic characteristics. Reported social benefits were common, including knowing one's status, prevention knowledge gained and improved communication with partners. Despite ubiquitous interest in using the kits, the majority of MSM could not afford to purchase test kits. SA guidelines have integrated HIVSS into HIV and testing policy, but little has been published regarding distribution channels of the kits for MSM and other key populations. There is a partnership between the National Department of Health and CBOs that specialise in key population programming to ensure MSM and other populations with unmet testing needs can access affordable test kits. We observed no social harms, and there were multiple social benefits. Consequently, we recommend immediate free or low-cost distribution of HIVSS kits to MSM through community-based initiatives. Future research should continue to assess optimised linkage to care. <![CDATA[<b>Protection of Personal Information Act No. 4 of 2013: Implications for biobanks</b>]]> The Protection of Personal Information Act (POPIA) No. 4 of 2013 is the first comprehensive data-protection regulation to be passed in South Africa (SA). Its objectives include giving effect to the constitutional right to privacy by regulating the way in which personal information must be processed, balancing the right to privacy against other rights, and establishing an Information Regulator to ensure that the rights protected by POPIA are respected. POPIA will have an impact on health research, including biobanks. As sharing of samples and data is a central feature of biobanks, POPIA could change the way in which data are obtained, shared and exported. In particular, the provisions regarding data minimisation, requirements pertaining to the transfer of data abroad, consent provisions and identification of the 'responsible person' will impact the operation of biobanks in SA. With POPIA soon to come into force, it is now time to consider its implications for biobanks in SA. <![CDATA[<b>The state of kidney transplantation in South Africa</b>]]> BACKGROUND: Kidney transplantation has been performed in South Africa (SA) since 1966. Transplants were initially limited to public hospitals, and the entry of the private sector heralded a new era in organ transplantation OBJECTIVES: To document kidney transplantation in SA and compare numbers, rates, trends and sources of kidneys transplanted in the public and private sectors in SA over 25 years METHODS: National kidney transplant data collected between 1991 and 2015 by the Organ Donor Foundation of South Africa were analysed. The total number of kidneys transplanted in the country was counted and rates were calculated. The numbers and rates in the private and public sectors were compared. The source of donor kidneys and sites where transplants were performed were documented RESULTS: Over the 25-year period under review, 7 191 kidney transplants were performed in SA. The overall kidney transplant rate was 6.4 per million population (pmp), averaging 4.8 pmp in the public sector and 15.2 pmp in the private sector; 58.3% of the donor kidneys were derived from deceased donors. Cape Town and Johannesburg hospitals performed 75% of the country's kidney transplants CONCLUSIONS: The overall transplant rate in SA is declining, especially in the public sector. Most kidney transplants in the country were performed in the public sector, and deceased-donor transplants predominated. Discrepancies exist in the allocation of kidneys. Recommendations are made on how the situation may be improved <![CDATA[<b>Reducing maternal deaths by skills-and-drills training in managing obstetric emergencies: A before-and-after observational study</b>]]> BACKGROUND: The institutional maternal mortality ratio (iMMR) in South Africa (SA) is still unacceptably high. A key recommendation from the National Committee on Confidential Enquiries into Maternal Deaths has been to improve the availability and quality of care for women suffering obstetric emergencies OBJECTIVES: To determine whether there was a change in the number of maternal deaths and in the iMMR over time that could be attributed to the training of >80% of healthcare professionals by means of a specifically designed emergency obstetric care (EmOC) training programme METHODS: A before-and-after study was conducted in 12 healthcare districts in SA, with the remaining 40 districts serving as a comparison group. Twelve 'most-in-need' healthcare districts in SA were selected using a composite scoring system. Multiprofessional skills-and-drills workshops were held off-site using the Essential Steps in Managing Obstetric Emergencies and Emergency Obstetric Simulation Training programme. Eighty percent or more of healthcare professionals providing maternity care in each district were trained between October 2012 and March 2015. Institutional births and maternal deaths were assessed for the period January 2011 - December 2016 and abefore-and-after-training comparison was made. The number of maternal deaths and the iMMR were used as outcome measures RESULTS: A total of 3 237 healthcare professionals were trained at 346 workshops. In all, 1 248 333 live births and 2 212 maternal deaths were identified and reviewed for cause of death as part of the SA confidential enquiries. During the same period there were 5 961 maternal deaths and 5 439 870 live births in the remaining 40 districts. Significant reductions of 29.3% in the number of maternal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.66 - 0.77) and 17.5% in the number of maternal deaths from direct obstetric causes (RR 0.825, 95% CI 0.73 - 0.93) were recorded. When comparing the percentage change in iMMR for equivalent before-and-after periods, there was a greater reduction in all categories of causes of maternal death in the intervention districts than in the comparison districts CONCLUSIONS: Implementing a skills-and-drills EmOC training package was associated with a significant reduction in maternal deaths <![CDATA[<b>The incidence of melanoma in South Africa: An exploratory analysis of National Cancer Registry data from 2005 to 2013 with a specific focus on melanoma in black Africans</b>]]> BACKGROUND: Melanoma is an aggressive skin cancer with poor survival when diagnosed late. There are important differences in clinical and histological features of melanoma and disease outcomes in people with darker skin types METHODS: A retrospective review of data captured by the National Cancer Registry (NCR) of South Africa (SA) was performed for 2005 -2013. Data on patient numbers, demography, location and biological features were analysed for all records. Closer analysis of melanoma of the limbs reported in black Africans was done after manually collecting this information from original reports RESULTS: With 11 784 invasive melanomas reported to the NCR, the overall incidence of melanoma for SA was 2.7 per 100 000. Males (51%), individuals aged >60 years (48%) and the anatomical sites of lower limb (36%) and trunk (27%) were most commonly affected. Melanoma incidences in the white and black populations were 23.2 and 0.5 per 100 000, respectively. Most cases were diagnosed at private pathology laboratories (73%). Superficial spreading melanoma (47%) and nodular melanoma (20%) predominated. Among 878 black Africans diagnosed in the public sector with melanoma of the limbs, females (68%) and individuals aged >60 years (61%) were most commonly affected. Lower-limb lesions (91%) and acral lentiginous melanoma (65%) predominated, with 74% of cases affecting the foot and 62% of cases presenting with a Breslow depth >4 mm CONCLUSIONS: This study provides up-to-date NCR incidence and demographic data on melanoma and highlights the neglected research gaps in relation to melanoma in black Africans to provide evidence needed to address health disparities in overlooked population groups <![CDATA[<b>How long does it take a registrar to complete the compulsory research project enabling specialist registration?</b>]]> BACKGROUND: The 2011 Health Professions Council of South Africa mandate requires a research component in the form of an MMed degree to permit specialist registration. Registrars consider that the time required to complete an MMed interferes with clinical training, service delivery obligations, and study and exam time. Net research time to completion is difficult to establish because MMed research activity is often intermittent, starting and finishing anywhere within the 4-year clinical training period. Conversely, gross dissertation completion time (DCT) is easily calculated by subtracting the ethics approval date from the dissertation submission date OBJECTIVES: To use gross DCT as a proxy to assess the time needed by registrars to finish the required research project. Additionally, the effect of four variables, namely dissertation format, clinical discipline, university research resources and the introduction of the 2011 ruling on gross DCT, was determined METHODS: The sample was 213 MMed dissertations, downloaded from the public domain. The dissertation submission date was subtracted from the ethics approval date to give the gross DCT in months. Descriptive analysis and χ² testing were used to determine the effects of the four variables on gross DCT, with significance set atp<0.05. A 12-month proposal preparation time was added to the gross DCT to fully reflect the MMed research timeline RESULTS: Sampled dissertations were from 2005 to 2017 and all eight MMed training universities were represented, as were 23 clinical disciplines. The mean (standard deviation) gross DCT was 31.0 (19.6) months, with a wide completion range of 0.2 - 109 months. When 12 months' proposal preparation time was added, gross mean research completion time rose to 43 months (31 + 12 = 43). A mere 41% of dissertations were sufficiently concluded to free up the final year for exam preparation. Gross DCT was not significantly affected by the 2011 requirement, university resources or clinical discipline. Dissertation format (publication ready v. monograph) significantly decreased gross DCT (p=0.01 CONCLUSIONS: Large standard deviations and a wide range of finishing times detract from the positive findings that most dissertations were completed within the 4-year clinical training time period. Publication-ready dissertations significantly shortened MMed completion time. Unique study and work commitments and lack of research experience challenge speedy MMed completion. Existing research and supervisory supportive structures should be remodelled to better suit the research needs of the andragogic specialist registrar <![CDATA[<b>Impact of Xpert MTB/RIF assay on multidrug-resistant tuberculosis treatment outcomes in a health district in South Africa</b>]]> BACKGROUND: Xpert MTB/RIF assay rapidly diagnoses rifampicin resistance, enabling early initiation of second-line tuberculosis (TB) treatment. However, the impact of an earlier multidrug-resistant TB (MDR-TB) diagnosis on treatment outcomes is unknown OBJECTIVES: To compare MDR-TB treatment outcomes in cases diagnosed with smear/culture and Xpert METHODS: This was a retrospective cohort study with cohorts defined by the diagnostic assay used in presumptive TB cases. Data were extracted from a drug-resistant (DR)-TB register including cases from January 2012 to June 2014. Treatment outcomes were assessed at recorded endpoints or after 2 years for those completing treatment RESULTS: A total of 718 cases were enrolled into the study. Cure rates were 43.4% (n=158) for the smear/culture cohort and 33.5% (n=118) for the Xpert cohort (p<0.01). Xpert diagnosis (adjusted risk ratio (aRR) 0.65;p=0.02) and male gender (aRR 0.66;p=0.04) were associated with cure outcome. Xpert diagnosis increased time to sputum culture conversion from 4 to 5 months (log-rank test p=0.01). Time to treatment initiation was not associated with treatment success in logistic regression analysis CONCLUSIONS: Despite rapid treatment initiation, MDR-TB treatment outcomes were poorer in patients diagnosed with Xpert MTB/RIF assay than in the smear/culture cohort, and they were also poorer in men than in women. Additional studies are required to assess possible factors influencing DR-TB outcomes <![CDATA[<b>Prevalence of comorbidities in women with and without breast cancer in Soweto, South Africa: Results from the SABC study</b>]]> BACKGROUND: Comorbidities occurring concurrently in breast cancer patients can be burdensome, as they may negatively influence time and stage of presentation OBJECTIVES: To describe the comorbid health conditions among South African (SA) black women with and without breast cancer and to determine factors associated with advanced-stage presentation of breast cancer METHODS: A population-based case-control study on breast cancer was conducted in black women in Soweto, SA, the SABC (South Africa Breast Cancer) study. Lifestyle information and blood samples were collected from 399 women with histologically confirmed new cases of invasive primary breast cancer, recruited prior to any therapy, and 399 age- and neighbourhood-matched controls without breast cancer. We compared self-reported metabolic diseases, depression, anthropometric measurements, blood pressure, HIV status and point-of-care lipid and glucose levels between patients with breast cancer and the control group RESULTS: In the whole population, the mean (standard deviation) age was 54.6 (12.9) years, the majority (81.2%) of the participants were overweight or obese, 85.3% had abdominal adiposity, 61.3% were hypertensive, 47.1% had impaired fasting plasma glucose, 8.4% had elevated total cholesterol, 74.8% had low high-density lipoprotein and 10.9% were assessed to be depressed. Ninety-one percent of the whole cohort had at least one metabolic disease. In the breast cancer group, 72.2% had one or more metabolic diseases only (HIV-negative and no evidence of depression), compared with 64.7% of the control group. From a multivariate logistic regression adjusted model, higher household socioeconomic status conferred a 19% reduction in the odds of having advanced-stage breast cancer at diagnosis, while hypertension, dyslipidaemia and HIV were not significantly associated with stage at breast cancer diagnosis in the adjusted model CONCLUSIONS: A large proportion of women experience several comorbidities, highlighting the need to address the chronic non-communicable disease epidemic in SA and to co-ordinate multidisciplinary primary-, secondary- and tertiary-level care in the country's complex healthcare system for better outcome <![CDATA[<b>A review of the use of high-flow nasal cannula oxygen therapy in hospitalised children at a regional hospital in the Cape Town Metro, South Africa</b>]]> BACKGROUND: High-flow nasal cannula (HFNC) oxygen is a non-invasive alternative to nasal continuous positive airway pressure (CPAP) therapy for infants and children requiring respiratory support. There is a paucity of data to support its use in children, with no published data from sub-Saharan Africa OBJECTIVES: To describe the outcomes of and adverse events related to HFNC in the first year of its use in a level 2 (L2) general paediatric ward, and to compare these outcomes with those of a historical cohort when this intervention was unavailable METHODS: This retrospective descriptive study included children aged <13 years who received HFNC in the first 12 months after its introduction (HFNC-availability group, n=66). Demographic data, clinical characteristics and outcomes (death, treatment failure, length of HFNC and HFNC-related adverse events) were assessed. A comparative description of children who required transfer to level 3 (L3) for any form of respiratory support (other than the available standard low-flow oxygen) during the 12-month period prior to HFNC availability (pre-HFNC group, n=54) was made. All analyses were performed in the paediatric wards, New Somerset Hospital, Cape Town, South Africa. Outcomes were compared using standard descriptive and comparative statistics RESULTS: The median age of the cohort was 5 months (interquartile range (IQR) 1.9 - 14.6). Sixteen children (13.3%) were malnourished, 10 (8.3%) were HIV-infected, and 30 (25.0%) had been born prematurely. The most common diagnoses were pneumonia, bronchiolitis and asthma. Asthma, anaemia and cardiac abnormalities were the most prevalent underlying comorbidities. Two children died in each group. All 54 children in the pre-HFNC group were transferred to L3; 38 (70.4%) needed CPAP or invasive ventilation. In the HFNC-availability period, 85 children were assessed as needing more than standard low-flow oxygen therapy: of the 19 immediately transferred to L3, 17 (89.4%) received CPAP or invasive ventilation; of the 66 who received HFNC at L2, 16 (24.2%) subsequently required transfer to L3 for CPAP or invasive ventilation. The median duration of HFNC was 46.3 hours (IQR 19.5 - 93.5) overall, and it was 12 hours (IQR 4 - 28) and 58.5 hours (IQR 39.5 - 106) for those who failed or were successfully managed on HFNC, respectively. No HFNC-related serious adverse events were recorded CONCLUSIONS: HFNC is a safe, effective, feasible option for non-invasive ventilation of children with respiratory illnesses in a resource-limited L2 setting. A greater proportion of children with lower respiratory tract infections in the HFNC-availability group than in the pre-HFNC group required support, but the intervention reduced the bed pressure on L3. Improved ways to identify HFNC failures would be beneficial <![CDATA[<b>Validation of a brief mental health screening tool for common mental disorders in primary healthcare</b>]]> BACKGROUND: Integrating care for common mental disorders (CMDs) such as depression, anxiety and alcohol abuse into primary healthcare (PHC) should assist in reducing South Africa (SA)'s quadruple burden of disease. CMDs compromise treatment adherence, health behaviour change and self-management of illnesses. Appropriate identification of mental disorders in primary care can be facilitated by brief, easy-to-administer screening that promotes high specificity OBJECTIVES: To establish the criterion-based validity of a seven-item Brief Mental Health (BMH) screening tool for assessing positive symptoms of CMDs in primary care patients METHODS: A total of 1 214 participants were recruited from all patients aged >18 years visiting 10 clinics as part of routine care in the Newcastle subdistrict of Amajuba District in KwaZulu-Natal Province, SA, over a period of 2 weeks. Consenting patients provided basic biographical information prior to screening with the BMH tool. PHC nurses remained blind to this assessment. PHC nurse-initiated assessment using the Adult Primary Care (APC) guidelines was the gold standard against which the performance of the BMH tool was compared. A specificity standard of 80% was used to establish cut-points. Specificity was favoured over sensitivity to ensure that those who did not have CMD symptoms were excluded, as well as to reduce over-referrals RESULTS: Of the participants, 72% were female. The AUD-C (alcohol abuse) performed well (area under the curve (AUC) 0.91 (95% confidence interval (CI) 0.88 - 0.95), cut-point >4, Cronbach alpha 0.87); PHQ-2 (depression) performed reasonably well (AUC 0.72 (95% CI 0.65 - 0.78), cut-point >3, alpha 0.71); and GAD-2 (anxiety) performance was acceptable (AUC 0.69 (95% CI 0.58 - 0.80), cut-point >3, alpha 0.62). Using the higher cut-off scores, patients who truly did not have CMD symptoms had negative predictive values (NPVs) of >90%. Overall, 26% of patients had CMD positive symptoms relative to 8% using the APC guidelines CONCLUSIONS: Using a higher specificity index, the positive predictive value and NPV show that at higher cut-point values the BMH not only helps identify individuals with alcohol misuse, depression and anxiety symptoms but also identifies a majority of those who do not have symptoms (true negatives), thus not overburdening nurses with false positives needing assessment. Research is needed to assess whether use of such a short and valid screening tool is generalisable to other clinic contexts as well as how mental health screening should best be introduced into routine clinic functioning and practice